A 70 year old male with pain in the right flank













 








 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solveb those patient's clinical problems with collective current best evidence based inputs.



This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


CASE:

A 70 year old male with chief complaints of pain in the right flank.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 years ago.He then complained of pain during micturation,difficulty in micturation, groin pain and occassional blood in urine.


He was taken to the hospital and was diagnosed with bladder calculi which was 25mm.He was given medication.

After a year of being on medication, he came to KIMS and was diagnosed with renal stone and horse shoe kidney.
Bladder stone was surgically operated.The renal stone was not operated as it was apparently small.

Now he is complaining of pain in the flank.He also complaints of bloating after having his meals for which he takes pantop
 (2-3 tablets in a week).


DAILY ROUTINE:

He wake up at 6am 
He has his tea at 7am.
Breakfast at 10 am for which he has rice and dal
He is a farmer by occupation and has his own land.
He has lunch by 2pm for which he has rice,dal,vegetables,meat and fish.
sleeps for 1-2 hours,wakes up and watches tv while having tea
Dinner at 10pm for which he has rice,dal and vegetables 
He goes to bed at 11:00pm.


PAST HISTORY:

Not a known case of DM,Asthma,Epilepsy and Thyroid abnormalities.

Patient was diagnosed with hypertension after he came to KIMS (29/11/2022).

History of stroke 25 years ago.



PERSONAL HISTORY:

Diet: mixed
Apetite: normal
Sleep: adequate 
Bowel and bladder: regular
Addictions: h/o tobacco chewing 5 years ago and alcohol 10 years ago.

FAMILY HISTORY: None


GENERAL EXAMINATION:

Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: clubbing of digits is present
Lymphadenopathy: absent
Pedal edema: absent

VITALS:

Temperature: 98.5 degree farenheit
Pulse: 80 beats per minute
Respiratory rate: 20 cycles per minute
Blood pressure: 140/80 mm Hg

SYSTEMIC EXAMINATION:

CVS: S1 and S2 are heard
Respiratory: bilateral vesicular breath sounds are present
CNS: no focal neurological deficits
Abdomen: soft and non tender















INVESTIGATIONS:


















PROVISIONAL DIAGNOSIS:

Right renal calculus with horse shoe kidney


TREATMENT:

Tab Ultracet
Tab Amlong 10mg OD

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